Objectives Participants will be able to: • Discuss the epidemiology and physiology of overdose; risk factors and response • Offer a 10 -20 minute overdose prevention training to other staff and clients 2

Physiology • Generally happens over course of 1 -3 hours- the stereotype “needle in the arm” death is only about 15% • Opioids repress the urge to breath – decrease response to carbon dioxide -leading to respiratory depression and death Slow breathing>Breathing stops>Heart stops>Circulation of blood to the brain stops 20

Legal Status- New Overdose Law in New York State (Effective April 1, 2006) • Protects the non-medical person who administers naloxone in setting of overdose from liability. – “shall be considered first aid or emergency treatment”. – “shall not constitute the unlawful practice of a profession”. • Allows the medical provider to provide naloxone for secondary administration. • NYSDOH created regulations for implementation of opioid overdose prevention programs. • Naloxone must be dispensed by MD, PA, NP by federal regulation 24

What is Naloxone? • Naloxone (Narcan) is an injectable opioid antagonist which reverses the effects of opioids preventing fatal overdose • What else will it do? 26

Naloxone (Narcan) • Opioid antagonist which reverses opioid overdose • Pushes most other opioids off the receptors, then sits on the receptor preventing it from being activated for 30 -90 minutes • Analogy- getting the wrong key stuck in a lock 27

Mixing Drugs: Major Risk for Overdose • Using an opioid with other depressants such as alcohol or benzodiazepines • Cocaine is a stimulant but: – High doses can reduce the respiratory drive – Wears off sooner than heroin in a speedball – Involved in about 53% of opioid overdose deaths in NYC 39

Prevention Messages • Use with others who know what to do if an overdose happens – make a plan • Be aware of companions at all times when using • Be careful if using alone, especially if: – Mixing different classes of drugs – Using after abstinence – (And watch out for others in these situations) • Use a trusted source – one that you know • “Taste” (test) your shot • Control your own shot 44

Stimulate the person overdosing • Shake, call name loudly • Sternal rub: rub knuckles hard up and down breast bone (it hurts!) (Ice can work but this is easier) 48

What NOT to do if a person is overdosing • • • Leave without calling 911 Salt shots Milk shots Cocaine shots Ice on genitals/ Shower Hitting or burning feet or fingertips 49

RESPONDING TO AN OPIOID OVERDOSE 50

Step One: Get Help • Call 911 - “My friend is overdosing and not breathing” • This phrase is more likely to bring paramedics with naloxone than EMT, who don’t carry it • Give location • Police may come • New 911 law 51

Check for breathing • Chest rising and falling • Nostrils moving in and out • Mirror or glass by nose or mouth will fog up • Touch moistened finger next to nostrils, feel for cool draft of inward breathing 52

Step Two: Rescue breathing alone can sustain someone until EMS arrives Mouth to mouth is using a dummy for practice (if available) Chest compressions not included (unless Responder is trained in CPR) 53

Rescue Breathing • Tilt back head to open airway • Hold nose, lift chin • Make a seal over the mouth with your mouth • Start with 2 quick breaths then one breath about every 5 seconds until EMS arrives or person breathes on their own. 54

Administration: Naloxone Injection • Inject into a muscle (subcutaneous and intravenous are also effective) • Acts within 2 -8 minutes • If no response in 2 -5 minutes, give 2 nd naloxone injection • Lasts for 30 – 90 minutes • (reminder that if 911 has not been called do it now!!) 56

Injection Technique • Inject into muscle of upper arm or front of thigh • Inject straight in, not at an angle • Rapidly push needle through skin into muscle and then push syringe to inject the medication • Depth of whole needle is fine (maybe less deep if person is skinny) • DON’T INJECT INTO THE CHEST, even if 57 you saw Pulp Fiction…

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Disposing of the Used Syringe • If safety syringe, engage sheath • Ask EMS to dispose of the needle or: • Take to any SEP, hospital or nursing home for disposal, call first! • Sharps accepted by some pharmacies and health care facilities • Call DOH for disposal site near you (800 -522 -5006) • Contact local Dept. of Public Works 59

Recovery Position • If you must leave the overdoser even for a few minutes put them into the recovery position so they won’t choke on vomit 60

Results: awake and breathing Narcan wears off in 30 -90 minutes • Don’t leave the overdoser alone as sedation may return • Reassure the overdoser if s/he is drug sick - the naloxone will wear off- don’t use more heroin to feel better!! • Encourage survivor to go to the hospital 61

Next Steps • Report use of Naloxone to the program • Anonymous report of date, place, drugs used and outcome • Get a refill of the Naloxone • Even if just one dose was used • If kit is lost • If kit is confiscated • If naloxone is nearing expiration date 62

Naloxone in Action • Reverses opiate effect of sedation and respiratory depression • Causes sudden withdrawal in the opioid dependent person – an unpleasant experience • No psychoactive effects – low potential for diversion, is not addictive • Routinely used by EMS (but in larger doses) • Has no effect if an opiate is not present 64

More about Naloxone • It is regulated but not a controlled substance • Need to obtain from a licensed prescriber • Should be stored at room temperature and away from direct light (in kit is OK) • Has a limited shelf life. Note expiration date and obtain replacement 65

More about Naloxone cont. • Emergency Medical Services give 1. 2 to 1. 6 milligrams of Naloxone which precipitates severe withdrawal in the dependent person • Overdose prevention services recommend starting with 0. 4 with an additional dose readily available – found to be effective in most instances 66

Heroin overdoses dropping Allegheny County Trends in Accidental Drug Overdose Deaths 2000 -2006* *Data is from Allegheny County Medical Examiners Annual Reports and includes all overdose deaths where these drugs were present at time of death, not necessarily cause of death.

Heroin Use in Allegheny County by Fiscal Year *Data from Pennsylvania Department Of Health

• "I did SOMETHING, you know, that made a difference. The whole world can’t see it but I know it made a difference. And that’s important. . . to me. " --quote collected by Suzanne Carlberg-Racich, Chicago “You get nervous, you know – someone’s blue, someone’s dying. But you do it because we are all out here together and people are going out right and left. ” --Boston man, age 29 "If you ever get in a meeting with some professional type people, tell ‘em that, you know, people like us– no, we’re not professionals, but if we have it at hand we can save somebody’s life with this stuff [naloxone]. . . it’s a lifesaver, there’s no question. " --Program participant in Chicago; Maxwell S, et al. J Addict Dis. 2006; 25(3): 8996. 79